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Oral Care is Critical Care
The Role of Oral Care in the Prevention of Hospital-Acquired Pneumonia
By Suzanne Pear, PhD, RN, CIC
Most critical care nurses, intensivists and included in VAP prevention success stories on its Bacteroides gingivalis mainly colonize the teeth
healthcare epidemiologists have read the statistics Web site.5 The American Association of Critical while Streptococcus salivarius mainly colonize the
about hospital-acquired pneumonia (HAP) and Care Nurses (AACN), recognizing the urgent need dorsal tongue. Another common commensal,
ventilator-associated pneumonia (VAP). Pneumo- for clarification, issued a Practice Alert in August Streptococcus mitis, is found on both buccal and
nia remains one of the most common causes of 2006 on the issue of “Oral Care in the Critically Ill.” tooth surfaces.8 These flora are usually considered
death worldwide. HAP is one of the most common This document specifies the need to “develop and low-level pathogens which may take years or
healthcare-associated (HAI) infections identified in implement a comprehensive oral care program for decades to produce clinically significant disease.
U.S. hospitalized patients, with 90 percent of the patients in critical care and acute care settings who Role of Saliva
300,000 annual HAP cases occurring in ventilated are at high risk for healthcare-associated pneumo- Another important component of oral health
patients (VAP).1 Nine to 27 percent of mechanically nia.”6 Such a program should include brushing is the continuous production of saliva, which
ventilated patients develop VAP, and one episode teeth, gums and tongue at least twice a day with a is essential to keeping the mouth and its com-
of VAP can increase the hospital length of stay by soft pediatric or adult toothbrush and moistening ponents clean and moist. Saliva is a mixed fluid
an average of nine days and the cost of care by oral mucosa and lips every two to four hours. secreted predominantly from the parotid, sub-
approximately $40,000.2 The AACN oral care guideline also recom- mandibular and sublingual glands. It provides
Sixty percent of healthcare-associated infection mends using an oral chlorhexidine gluconate a number of important functions such as wash-
(HAI) deaths are due to HAP/VAP. Most articles on (0.12 percent) rinse twice daily, but only on adult ing food debris and unattached microorganisms
the subject of HAP/VAP usually begin by quoting cardiac surgery patients during their periop- from the mouth. In addition, saliva contains a
similar facts and figures, in order to gain our atten- erative period.6 As part of VAP prevention, the number of immune substances such as immuno-
tion and remind us how costly HAP/VAP is in terms Association for Professionals in Infection Control globulin A which obstructs microbial adherence
of patient lives and healthcare dollars. This is good, and Epidemiology (APIC) exhorts clinicians to in the oral cavity and lactoferrin which inhibits
as we need to be reminded and constantly vigilant make “patient oral hygiene standard practice” bacterial infection in the healthy individual.9 The
in our HAP/VAP prevention efforts. for ventilated patients.7 dorsal surface of the tongue often traps residual
Another positive impact is that organizations Aligning with the CDC, this clinical guidance debris not removed during swallowing and is
like the Institute for Healthcare Improvement’s document describes oral hygiene as consisting known to harbor millions of organisms. Routine
(IHI) “Lives Saved” campaigns’ VAP bundle3, the of “frequent tooth brushing, oral suctioning tongue cleaning is not generally performed by
American Thoracic Society (ATS) pneumonia man- and swabbing of the mouth with antiseptic either patients or care providers.10
agement guidelines2 and the Centers for Disease agents.”7 According to this healthcare worker Oral Environment of Critically Ill
Control and Prevention (CDC)’s HAI pneumonia (HCW) education publication, making routine The oral flora of critically ill adults differs
prevention guideline,4 have provided programs oral hygiene a standard patient care intervention from that of healthy adults and contains organ-
so that clinicians everywhere understand the has been found to reduce the incidence of VAP isms that can rapidly cause pneumonia. Within
synergistic benefits of bundling evidence-based by 57.6 percent. 48 hours of admission, the composition of the
practices to prevent HAP/VAP. oropharyngeal flora of critically ill patients under-
We now know there is no single patient-care goes a change from the usual predominance of
intervention that will eliminate HAP/VAP and that gram-positive streptococci and dental pathogens
these bundles or guideline components need to to predominantly gram-negative organisms, con-
be reliably performed for the full benefits to be stituting more virulent flora, including pathogens
realized. Although not all of the evidence-based that can cause HAP/VAP within hours or days.11
HAP/VAP prevention guidelines recommend the Also, increased levels of proteases in the oral
same strategies, one intervention that has been Figure 1. Sites of bacterial attachment in the mouth secretions of critically ill patients remove from
recognized as a core or adjunct component of a their epithelial cell surfaces, a glycoprotein sub-
pneumonia prevention program is comprehensive Why Comprehensive Oral Care stance called fibronectin. Normally, fibronectin
oral care/oral-hygiene. The purpose of this article is Necessary to Prevent VAP is present on cell surfaces and acts as a host
is to help connect the clinical dots between the Normal Oral Flora defense mechanism by blocking pathogenic
reliable provision of comprehensive oral care and In order to appreciate why oral care is essential bacterial attachment to oral and tracheal mucus
HAP/VAP prevention. for VAP prevention, it is necessary to understand membranes. This depletion of fibronectin in the
the mouth of a healthy adult as well as the criticall ill allows cell receptor sites to replace
What Is Comprehensive Oral Care? changes that occur in the mouth of the critically normal flora with virulent pathogens such as
The CDC’s pneumonia guideline discusses the ill patient soon after admission into the health- Staphylococcus aureus and different strains of
need to “develop and implement a comprehen- care setting. Most oral bacteria are considered gram negative bacteria, including Pseudomonas
sive oral-hygiene program …for oropharyngeal to be part of the patient’s normal flora and may aeruginosa and Acinetobacter on buccal and
cleaning and decontamination with an antisep- consist of up to 350 different species. Various pharyngeal epithelial cells.8
tic agent”4 but leaves the specific procedures to organisms tend to colonize different surfaces in If the critically ill or intubated patient does not
clinicians. Although the IHI’s VAP bundle doesn’t the mouth. For example, Streptococcus mutans, receive effective, comprehensive oral hygiene,
include oral care as a core measure, it is frequently Streptococcus sanguis, Actinomyces vicosus and then dental plaque and hardened bacterial depos-
ICT continuing education
its may develop on the teeth within 72 hours. identification of oral hygiene problems.
This is followed by emerging gingivitis, gum Dental Plaque Removal
inflammation, infection and a subsequent shift • Intervention: Use a small, soft toothbrush
from primarily Streptococcus and Actinomyces to brush teeth, tongue and gums at least
spp. to increasing numbers of aerobic gram-neg- twice daily to remove dental plaque. Foam
ative bacilli.10 Since adhesion to a surface in the swabs or gauze should not be used, as
mouth is important for the continued existence they are not effective tools for this task.
and proliferation of organisms, bacteria which • Rationale: Dental plaque, identified as a
attach to the tooth surface gradually coalesce to source of pathogenic bacteria associated
produce a biofilm and after further development, with respiratory infection, requires
lead to the formation of dental plaque.9 mechanical debridement from tooth,
tongue and gingival surfaces.
Xerostomia and Mucositis in the Toothpaste
Critically Ill Patient • Intervention: Use toothpaste which
Xerostomia is dry mouth and mucositis means contains additives that assist in the
oral inflammation. Studies by Dennesen et al. breakdown of mucus and biofilm in the
have documented a nearly absent salivary flow mouth.
Figure 2. The Pathway to VAP
in intubated sedated ICU patients which can be • Rationale: Additives such as sodium
explained by several circumstances such as the tube hampers natural host protection and secre- bicarbonate have been shown to assist
severity of the disease resulting in intubation and tion clearance mechanisms. It bypasses normal in removing debris accumulations on oral
admission to the ICU, lack of normal oral intake, air filtration and physical capture of microorgan- tissues and teeth.
fluid balance disturbances, extended use of mor- isms and particulates. The ET tube also blocks the Antiseptic Mouth Rinse
phine required because of controlled mechanical mucociliary clearance mechanism as well as dis- • Intervention: Use an alcohol-free, antiseptic
ventilation or pain management.12 ables the cough reflex and inhibits phagocytosis rinse to prevent bacterial colonization of
Apart from the inadequate flow, the saliva is in the alveoli. Its very presence initiates “foreign the oropharyngeal tract.
not distributed through the oral cavity in a supine body” reaction in the tracheal tissues, increasing • Rationale: Mouthwashes with alcohol cause
sedated patient and severe xerostomia, severely secretory and inflammatory responses. excessive drying of oral tissues. Hydrogen
reduced salivary flow and dry mouth, is therefore In addition, the ET tube acts as a direct peroxide and CHG-based rinses have been
generally present in ICU patients. As the mucus conduit for pathogen access into the lungs, shown to assist in removing oral debris as
membranes of the mouth dry out, the tissues allowing a biofilm or “slime layer” to form that well as provide antibacterial properties.
become inflamed. A severe reduction of salivary allows microbes to multiply on its surface, which Moisturizer
flow and subsequent xerostomia and mucositis can then dislodge and drop into the lungs. • Intervention: Use a water-soluble
may result in increased oropharyngeal coloniza- Over pressure of the ET tube cuff can damage moisturizer to assist in the maintenance of
tion with respiratory pathogens. As mucositis or (necrose) the tracheal wall, potentially caus- healthy lips and gums at least once every
oral inflammation increases in the hospitalized ing long term damage as well as providing an two hours.
and ventilated patient’s mouth, the level of oral inflamed site for bacteria migration and growth. • Rationale: Dryness and cracking of
bacteria increases as well. The greater the level Contaminated secretions or dislodged biofilm oral tissues and lips provide regions for
of oral bacteria, the greater the amount of bio- particles fall into the lungs directly through the bacterial proliferation. A water-soluble
film that attaches to the patient’s teeth. Allowing ET tube or around the ET tube cuff. The lungs moisturizer allows tissue absorption and
build-up of biofilm and resultant dental plaque, become contaminated with pathogenic micro- added hydration.
if not removed, increases the bacterial load in organisms which may additionally proliferate Avoid Lemon Glycerin Swabs
oropharyngeal secretions. Given the fact that all within the lung tissue. This cycle of contami- • Intervention: Avoid using lemon-glycerin
patients aspirate secretions, even non-ventilated nation, aspiration and pathogen multiplication swabs for oral care to moisten oral mucosa.
patients, the greater the amount and microbial continues. If these pathogenic microorganisms • Rationale: Lemon-glycerin compounds are
contamination of aspirated secretions, the more overwhelm the body’s antibacterial defenses, acidic and cause drying of oral tissues.
likely that lung infection, i.e., HAP/VAP will occur. the patient develops pneumonia. Assessment of Oral Cavity16
Therefore, a critical component of any evidence- • Intervention: Conduct an initial admission
based HAP or VAP prevention bundle must be the The Recommended Interventions and as well as daily assessment of the lips, oral
prevention of plaque formation by ensuring that Rationales of a Comprehensive Oral tissue, tongue, teeth, and saliva of each
patients perform or receive thorough oral care, Care Protocol patient on a mechanical ventilator.
especially mechanical debridement of biofilm Recommended oral care interventions for • Rationale: Assessment allows for initial
and plaque at least twice daily.13 Comprehensive all hospitalized patients16 identification of oral hygiene problems and
oral care interventions should focus on plaque Written Protocol and Training for continued observation of oral health.
removal and stimulation of salivary flow.14 • Intervention: Written oral care protocol Elevate Head
and training should be in place. • Intervention: Keep head of bed elevated
The Pathway to VAP • Rationale: Policy is designed to provide at least 30 degrees, and position patient
Why are ventilated patients more susceptible a standard of care which should be so that oral secretions pool into the
to pneumonia? Two words – endotracheal (ET) reinforced in training and should allow for buccal pocket; especially important during
tube. The ventilated patient’s normal defenses are consistent care of all patients. feeding, brushing teeth, etc.
hampered, bypassed, blocked or disabled during Initial Assessment • Rationale: Elevation prevents reflux
endotracheal tube-assisted mechanical ventilation • Intervention: Conduct an initial admission and aspiration of gastric contents; oral
by the physical presence of the assistive-breath- assessment of the patient’s oral health and secretions may drain into the subglottic
ing device as well as by medications used to keep self-care deficits. area where they can become rapidly
these patients sedated.15 The presence of the ET • Rationale: Assessment allows for initial colonized with pathogenic bacteria.